Relational Autonomy and Support for Autonomy: A Commentary on "Relational Autonomy as a Theoretical Lens for Qualitative Health Research" by Jennifer A. H. Bell

Susan Sherwin's approach to bioethics promotes more inclusive and less oppressive sociopolitical environments within healthcare for marginalized groups. Sherwin's relational theory of autonomy endorses this aim in targeting live options as bellwethers for recognizing contexts constraining or promoting autonomy. Those contexts closing off certain options as pursuable in practice limit autonomy while those promoting a plurality of practically pursuable courses of action are autonomy enhancing. Attending to what is possible in practice is thus key to understanding how autonomy is impacted. In healthcare contexts, those implicated in social structures systematically limiting autonomy sustain oppressive contexts affecting those marginalized on multiple levels, including access to healthcare, healthcare policies and guidelines, and patient-healthcare provider relations. Motivated by Sherwin's approach, Jennifer Bell (2020) offers practical guideposts to promote patient autonomy on such levels within healthcare.

Bell provides an approach to relational autonomy illuminated by her experience conducting cancer clinical trials, pointing to clinical trial personnel as potential key proponents for upholding patient autonomy through engaging patients in shared decision making processes, providing relevant information to them, and including support persons in patient decisions (such as the patient's family or friends). Bell's main project is to provide a practical "how to" guide to encourage and promote researchers to sustain and support patient autonomy when conducting clinical trials. This practical aim is instructive because of its focus on support for relational autonomy. Below, I offer two positive implications. I then conclude by noting two concerns that may dampen some of this optimism, but for the greater purpose of attending to constrained live options that might arise even with positive support for autonomy.

One positive implication of advocating support for autonomy is that it encourages a shift away from a simple focus on respect for autonomy. For practitioners within healthcare contexts, respect for patient autonomy is often understood as a matter of gaining informed consent. Moving from a theoretical lens of respect for autonomy to support for autonomy moves from the framework of autonomous authorization toward an appreciation for the process of how individuals arrive at the ability to autonomously authorize their consent. Support for autonomy requires recognizing personal, relational, and structural factors affecting conditions requisite to autonomy competencies or capacities. Presumably, the aim to support patient autonomy comes with correlative motives to respond to such factors. Although it is unclear how far Bell's practical guide urges such response, emphasizing support for the process of autonomous decision-making is valuable to appreciating the practical significance of a relational autonomy view. One way support for autonomy might play out in research contexts, as I see it, is for researchers to reflectively engage with the social, economic, or political situations of participants. Reflection here might include attending to what research methods are utilized or which researchers are involved in the study, as well as considering how either affects research outcomes in light of participants' ability to contribute to a particular study's aims and goals. Since particular contexts matter to participants' abilities to choose, support for relational autonomy bears practical import for participation in clinical trials. Theoretical implications are meaningful here as well. Attention to how researchers and methods are implicated can affect what knowledge is generated by the research. Researchers' effects on study design, data collection, and analysis may all reflect bias or selective focus orienting outcomes in favor of research goals that are unduly influenced by positions of power and privilege in relation to research participants. Thus, attention to supporting autonomy bears further significance for knowledge produced through research.

A second positive element of Bell's approach to supporting relational autonomy is that it encourages epistemic humility, a virtue that seems key to effective healthcare research (Wardroope 2015; Hutchison et al. 2017) and healthcare delivery (Marcum 2009, Schwab 2012, Peleb 2018). Through connecting support for autonomy to epistemic humility, Bell demonstrates how to foreground attention to patient autonomy over researchers' own interests. In research trials, researchers can express epistemic humility by placing more emphasis on understanding potential issues, aims...